Telemedicine and Consent Form

Telemedicine and Consent Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name if signed by other than the patient

First NameLast Name
Relationship to the patient
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of preferred pharmacy:*
Phone # of preferred pharmacy:*
Age:*
Gender:*

FemaleMaleOther
First day of last menstrual period if applicable:

MonthDayYear
Date
Pregnant

YesNoMaybe
What are your symptoms / concerns today?
When did your symptoms start?
Allergies to Medications?*

NoneYes (Please List)
Medication Allergies and reaction:
Current Medications*

NoneYes (Please List)
Medication List:
Medical Conditions:*

No Medical ConditionsHeart problemsLung problemsDiabetesHigh Blood PressureHistory of Altitude SicknessThyroid diseaseHistory of past Covid infectionHistory of High Altitude Pulmonary EdemaOther (Please List)
Medical conditions: (please list / describe)
Surgeries*

NoneYes (please list)
Surgeries (Please list):
Family Medical History*

NoneYes (please list)
Family Medical History (please list/describe):
Social History:
Smoke Cigarettes*
Number of cigarettes
Drink Alcohol*
Number of drinks
Recreational Drug Use*
Introduction

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
Please check that you understand all of the following:*

I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.I understand that I may opt out of the telehealth visit at any time without loss or withdrawal of treatment.I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Colorado at the time of this service.I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to: •It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures. •Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network. •Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.I agree that information exchanged during my telehealth visit will bemaintained by the healthcare providers,and healthcare facilities involved in my care.I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).I understand that I must take reasonable steps to protect myself fromunauthorized use of my electronic communications by others.The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.I understand that I have a responsibility to verify the identity and credentialsof the healthcare provider rendering my care via telehealth and to confirm thathe or she is my healthcare provider.I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.By signing below, I understand the inherent risks of errors or deficiencies in theelectronic transmission of health information and images during a telehealth visit.I understand that there is never a warranty or guarantee as to a particularresult or outcome related to a condition or diagnosis when medical care isprovided.To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visitI understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.I, , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
Please sign:*

Clear
MEDICARE OPT OUT PRIVATE CONTRACT

• I, Leslie Shook and Danielle Shook (High Altitude Mobile Physicians), have been excluded from Medicare under §§1128, 1156 or 1892 of the Act.
• I, the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
• I, the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
• The expected or known effective date and expected or known expiration date of the opt-out period is April 1, 2018 through April 1, 2022.
• I, the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• This contract cannot be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)
• I, the beneficiary or the beneficiary’s legal representative will receive or have received a copy (a photocopy permissible) of this contract, before items or services are furnished to me under the terms of this contract.
Patient Signature:

Clear
YOUR PROVIDER WILL COMPLETE THE SECTION BELOW.

PLEASE CLICK ON SUBMIT NOW.
Assessment
Date:

MonthDayYear
Provider:
CC:
HPI:
General (abnormal vs, fever, anxious, tired etc.):

NormalAbnormal (specify)
HEENT:

NormalEyesAbnormal (specify)
Right Eye:

PainfulIrritatedForeign body sensationWears contactsBlurred visionLack of visionOrbital pain (bone)Mucoid drainageClear drainageRednessItchingOther symptoms (specify)
Left Eye:

PainfulIrritatedForeign body sensationWears contactsBlurred visionLack of visionOrbital pain (bone)Mucoid drainageClear drainageRednessItchingOther symptoms (specify)
Skin:

NormalAbnormal (specify)
Heart:

NormalAbnormal (specify)
Lungs / breathing:

NormalAbnormal (specify)
Neck / lymph nodes:

NormalAbnormal (specify)
Abdomen:

NormalAbnormal (specify)
Genital/ Urinary:

NormalUTI symptomsAbnormal (specify)
dysuriablood in urineurinary urgencyurinary frequencycloudy urineodor to urineflank painvaginal discharge
Neurologic:

NormalAbnormal (specify)
Musculoskeletal:

NormalAbnormal (specify)
Physical Assessment via audio or video:
Diagnosis:
Patient Education:
AMSURIPharyngitisUTIOrthoEYE
AMS Education:

Diet and hydration: Eat smaller, more frequent meals that are higher in carbs and lower in protein and fat (harder to digest). Sip on water throughout the day. Drinking too much too fast can cause stomach upset. Drink enough to keep your urine pale yellow to clear. For infants, watch for normal diaper count.Activity: It is recommended to limit strenuous activity the first 48 hours at altitude while your body adjusts. Unless on continuous oxygen, activity as tolerated after treatment.Sunglasses/ sunscreen: Sunburns and snow blindness are a serious risk at this altitude and with the sun reflecting off the snow.Alcohol: Alcohol slows your breathing rate which lowers your oxygen level. It can worsen your symptoms.Call your provider for any questions or concerns.Other
UTI Education:

Increase fluid intakeMay take AZO for urinary discomfort as directed for maximum of 3 daysIf you develop fever, vomiting or back pain, seek care in the emergency room.Contact provider with any questions or concernsOther
URI Education:

Ibuprofen or Tylenol as directed for discomfortIncrease hydrationOTC nasal steroid (ie: Flonase) as directed on packageGuaifenesin (Mucinex) as directed on packagePseudoephedrine (Sudafed) as directed on packageDextromethorphan (Delsym) as directed on packageOxymetazoline (Afrin nasal spray) as directed on package, no more than 3 consecutive daysContact provider with any questions or concernsOther
Pharyngitis Education:

Ibuprofen or Tylenol as directed for discomfortWarm-salt water gargles as needed for discomfortIf antibiotics ordered, switch to new toothbrush 24 hours after starting medicationContact provider with any questions or concernsOther
Ortho Education:

Ibuprofen or Tylenol as directed for discomfortGentle range of motion- not to the point of painIce for the first 24 hours- 20 minutes on, 20 minutes off while awakeKeep extremity elevated while restingNo weight bearingFollow up with orthopedist for re-evaluation asapContact provider with any questions or concernsOther
Eye Education:

Ibuprofen or Tylenol as directed for discomfortClean eyelids with warm water and paper towel and disposeWash hands frequently and avoid touching eyesDispose of contacts and wear only glasses until infection completely resolvedDispose of eye make up as it will be contaminatedAny loss or change of vision seek emergency care immediatelyContact provider with any questions or concernsOther
ICD-10 Diagnosis Code (Eye):
ICD-10 Diagnosis Code:
Other ICD-10
Other ICD-10 code
Other ICD-10 code
Other ICD-10 code
Plan:
RX:
*Ciprofloxicin ophthalmic 0.3% solution: 1-2 drops in affected eye every 2 hours while awake for 2 days then every 4 hours for 5 days.

*Macrobid 100mg PO q 12 hours x 5 days

*Cyclobenzaprine 5-10mg PO TID prn muscle spasms

*Augmentin 875mg/125mg PO q 12 hrs x 7 days
Follow up:
CPT Procedure Code:
Provider Signature:

Leslie Shook NP-C
Provider Signature:

Danielle Shook NP-C
Provider Signature:

Lisa Roberts NP-C
Should be Empty:

Telemedicine and Consent Form

Social History:

Assessment

Patient Education:

Provider Signature:

Provider Signature:

Provider Signature: